End-of-Life Decision-Making

Medical treatments in the weeks and days before death consume a disproportionate amount
of health care spending, and can often lead to unnecessary suffering and unwanted
medical interventions. But a myriad of factors makes it difficult for both practitioners
and loved ones to respect patient autonomy and treatment preferences at the end of
life.

"Matching our treatment goals to the values and preferences of the individual is a
key part of ethically sound practice," says SPH alumnus Darin Zahuranec, MD, MS '09, an assistant professor of neurology in the U-M Health System who studies
end-of-life decision-making.

Zahuranec notes that even when people attempt to give specific instructions to those
who may actually make life-or-death decisions on their behalf—as with advance directives—evidence
shows that such instructions typically do not account for all of the treatment decisions
that may arise.

Further, different health conditions present different challenges. Patients facing
a terminal illness, such as cancer, may have opportunities to discuss end-of-life
treatment preferences with their families and doctors. But when a sudden unexpected
illness, like a stroke, occurs, many patients and families are unprepared—especially
as decisions often need to be made quickly, and the patient may be unable to communicate.
This is particularly true with acute brain hemorrhage, a type of stroke with very
high rates of early mortality. In about 70 percent of cases of acute brain hemorrhage,
the withdrawal of life-sustaining treatment (e.g., a ventilator) precedes death. In
such cases, family members are often placed in a position of making life-and-death
decisions about treatment.

In a new study funded by the National Institutes of Health, Zahuranec and his team
are exploring the decision-making processes that family members of people with brain
hemorrhages undergo when considering treatment options. "In many cases, doctors and
family members face a tradeoff between the possibility of death or survival with some
disability, but our ability as practitioners to predict the impact of this disability
on someone's quality of life is imperfect," Zahuranec says. " We're learning more
about just how difficult this is for people, and we hope to be able to improve this
process in the future."

Zahuranec's research is a powerful reminder that, while no advance decision-making
can guarantee what happens near the end of a patient's life, if loved ones and practitioners
address these issues ahead of time, they may find it easier to make sound treatment
decisions for—and respect the autonomy of—the patient.

—Jillian Murphy, MPH '09, Project Manager, U-M Stroke Program

End-of-Life Decision-Making: What You Can Do Now

Consider your values and what is important to you. We are all going to die; how we
die remains uncertain. It is fair to expect that our self-determination and autonomy
as individuals be respected in all our medical treatment.

Talk to your loved ones and doctors about your various treatment preferences, and
continue to have these conversations as your health status changes.

Take the time to formally grant durable power of attorney (DPOA) for health care to
someone you trust so that person can make medical decisions for you in the event you
are unable to speak for yourself.

For more information, visit Caring Connections, a program of the National Hospice and Palliative Care Organization. (Click on "Planning
Ahead" for additional resources)

Medicare Savings

Since the early 1980s, Medicare has paid for kidney dialysis for any American who
needs it, regardless of age. But because until recently Medicare paid a flat rate
for basic dialysis treatment and associated tests and drugs, and a separate fee-for-service
rate for additional medications and lab tests, costs kept going up. So Congress ordered
the Centers for Medicare & Medicaid Services (CMS) to come up with a new bundled-payment
system that would allow Medicare to pay a flat rate for dialysis, medications, and
tests. CMS in turn asked the U-M Kidney Epidemiology and Cost Center (KECC) to develop the system.

"We looked at multiple years of claims data to determine what drugs and tests should
be in the system, and we built a case-mix adjustment model as well," says Richard Hirth, associate director of KECC and professor and associate chair in the Department of
Health Management and Policy. The goal was to build a cost-effective system that would
provide equal access to all patients, regardless of how expensive their treatments
were.

CMS implemented the new dialysis-payment system in 2011, and since then the use of
injectable medications has dropped by approximately 25 percent, and Medicare payments
for dialysis have gone down by two percent—or about $225 million per year. Dialysis
facilities themselves are profiting because their costs have dropped by as much as
ten percent. It's therefore expected that CMS will be able to reduce payments even
further in the future. The new system also makes it easier for patients to receive
dialysis in their homes. Hirth says the dialysis-payment system is the latest in a
long-standing movement toward bundled-payment systems by both public and private payers.
For more visit sph.umich.edu/kecc.